Sonia Agarwal, M.Sc
Clinical Psychology Ph.D. Student
School of Psychology, Fielding Graduate University
Amanda Bertsch, M.S., CCC-SLP
Clinical Psychology Ph.D. Student
School of Psychology, Fielding Graduate University
Mia Angeliese, M.S., CSP
Clinical Psychology Ph.D. Student
School of Psychology, Fielding Graduate University
Jessica Emick, PhD
Core Faculty
School of Psychology, Fielding Graduate University
Autism spectrum disorder (ASD) is a neurodevelopmental disorder that is characterized by challenges in social interaction and communication, repetitive behaviors, having a limited range of specific interests, differences in sensory processing, emotional and behavioral dysregulation, and difficulties adapting to change and managing emotions (Balasco et al., 2020; Maenner et al., 2012; Martínez-González et al., 2022; Samson et al., 2014). Current research concerning ASD recognizes that common health-related comorbidities (such as sleep disturbances, anxiety, and gastrointestinal disorders) can significantly affect the quality of life of individuals with ASD (Ferguson et al., 2019; Maenner et al., 2012). Studies demonstrate that gastrointestinal symptoms, such as constipation, diarrhea, and abdominal pain, affect roughly 33% of individuals diagnosed with ASD, a much larger proportion than the 13.5% prevalence observed in neurotypical control groups (Aldinger et al., 2015; Garcia-Gutierrez et al., 2020; Lasheras et al., 2023).
Gastrointestinal problems in individuals with ASD may cause behavioral issues that stem from physical discomfort, such as irritability, aggression, and self-injurious actions (Maenner et al., 2012). Both Leader and colleagues (2020) and Maenner and colleagues (2012) emphasize that gastrointestinal problems can also exacerbate existing behavioral challenges, such as mood dysregulation, defiance, and aggression. It is hypothesized that the gut-brain axis is implicated in the relationship between gastrointestinal difficulties and worsened ASD-related symptomology (Aldinger et al., 2015; Garcia-Gutierrez et al., 2020). The increasing recognition of these interconnected challenges prompts further research into the interactions between gastrointestinal disorders and ASD, including how interventions targeting gastrointestinal health may play a role in reducing behavioral symptoms and improving quality of life (Lasheras et al., 2023; Leader et al., 2020). While it is important to understand how GI issues may negatively impact behaviors, functioning, and quality of life, it is also necessary to view child and adolescent well-being from a strengths-based framework such as flourishing. Flourishing focuses on the positive aspects of a child’s overall well-being like curiosity and emotional regulation skills (Lippman et al., 2014). Current research suggests that children with autism are less likely to flourish compared to their typically developing peers due, in part, to social and behavioral difficulties (Hilton et al., 2019). Flourishing is a valuable construct to investigate because it is associated with higher levels of school engagement (Durlak et al., 2011), greater resilience (Bethell et al., 2019), and improved mental health outcomes (Burns et al., 2022). Children who demonstrate strong flourishing tend to exhibit better emotional regulation, positive social connections, and academic motivation (Bethell et al., 2019). Within the context of ASD, research on flourishing shifts away from a traditional deficit-focused model of functioning and more towards an understanding of overall well-being for children and adolescents with ASD.
Our Study
To better understand the relationship between autism and GI issues and how it impacts flourishing, we analyzed data from the 2022 National Survey of Children’s Health (NSCH) (Resource Center for Child and Adolescent Health, 2019). The NSCH is a large, nationwide survey that collects data across various aspects of children’s health and development. Data was randomly collected across households in the United States that have one or more children between the ages of 0 and 17 years old.
In this study, flourishing was measured using the 2022 National Survey of Children’s Health (NSCH) child flourishing index (CFI), which includes three key questions:
- Does the child show interest and curiosity in learning new things?
- Does the child work to finish tasks he or she starts?
- Does the child stay calm and in control when faced with a challenge?
Parents answered these questions that were designed to capture critical aspects of emotional regulation, persistence, and engagement. This approach allows for a more holistic view of well-being, focusing on strengths that support positive outcomes for all children, including those with autism (Hilton et al., 2019).
Our sample included 33,727 children and adolescents (ages 6-17) whose parents or guardians responded to the survey. Gastrointestinal issues (GI) were identified through a yes/no item indicating chronic digestive problems (e.g., stomach/intestinal difficulties, constipation, or diarrhea) within the past 12 months. ASD was determined by parent report of both a lifetime ASD diagnosis and current ASD status. Flourishing, our outcome variable, was operationalized based on parent-reported indicators of social, emotional, and behavioral well-being. A two-block logistic regression was conducted: the first block included demographic factors (race/ethnicity, gender, age, socioeconomic status, specialist healthcare needs, insurance adequacy), and the second block introduced the ASD-GI status variables to assess predictive utility on flourishing.
Overall, 6.9% of children in the sample had GI issues, 3.2% had ASD, and 0.7% had both ASD and GI problems. Of the 3.2% of children with ASD, 20% also had gut issues; of the 6.9% of children with GI issues, 9% also had ASD. After controlling for demographic variables, co-occurring ASD and GI issues emerged as a significant predictor of lower flourishing. Specifically, children with both ASD and GI issues were 12 times less likely to be reported as flourishing compared to children without ASD or GI problems, 5.7 times less likely than those with GI issues but not ASD, and two times less likely than those with ASD but no GI issues (all p < .001). These findings suggest that the combination of ASD and GI problems presents a unique risk factor beyond the additive effects of either condition alone.
Discussion
The strong association between ASD and GI challenges highlights the need for multidisciplinary collaboration among pediatricians, gastroenterologists, educators, and health psychologists. For health psychologists, these findings offer several actionable recommendations.
First, health psychologists can collaborate with pediatric primary care providers and gastroenterologists to ensure comprehensive GI assessments for children with ASD. With nearly 20% of these children in our sample experiencing GI issues, establishing open communication through regular interdisciplinary consultations is vital. This collaborative framework supports adherence to best practices, such as those guidelines published by the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN), and allows for gastroenterologists and psychologists to share insights on how GI symptoms may influence psychological well-being. Research shows that persistent gastrointestinal discomfort can worsen behavioral dysregulation and emotional challenges (Leader et al., 2020; Maenner et al., 2012), potentially hindering a child’s flourishing.
Second, health psychologists and medical providers can promote early screening and proactive intervention strategies. Routine screening for GI symptoms in children diagnosed with ASD can help to identify and mitigate risks before challenges escalate. Incorporating gastrointestinal pain rating scales (e.g., Gastrointestinal Symptom Severity Scale [GSSS]; Martinez-Gonzalez et al., 2024) into psychological assessments can help account for physical discomfort and its potential impacts on a child’s performance, allowing for a more accurate interpretation of a child’s current functioning and subsequent timely referrals and interventions to address these concerns.
Finally, health psychologists should stay informed about the gut-brain axis, which plays a crucial role in regulating mood and behavior (Aldinger et al., 2015; Garcia-Gutierrez et al., 2020). Integrating this knowledge into assessments and interventions enables psychologists to tailor their approaches to address both the cognitive-emotional needs and the secondary impacts of GI distress. For example, adapting cognitive-behavioral strategies can help a child manage anxiety symptoms linked to social or sensory challenges as well as discomfort from GI issues.
In summary, the intersection of ASD and GI challenges demands a collaborative, integrated care approach. Health psychologists are well positioned to bridge behavioral and medical management, thereby improving outcomes and promoting flourishing in children with ASD and GI issues.
References
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